Ligating instrument and methods of ligating tissue in endoscopic operative procedures

ABSTRACT

A ligating instrument includes a handle for securing a proximal end of a ligating device externally of the body with one hand, the ligating device defining a lumen for passage therethrough of a length of ligature material formed with a ligature loop for being disposed externally of a distal end of the ligating device to be positioned around anatomical tissue to be ligated within the body, and an operating member coupled with the ligature material for being manually moved with the same hand as that securing the ligating device proximal end to pull the ligature material through the ligating device to form a ligature with the ligature loop in the anatomical tissue. A method of ligating tissue in endoscopic operative procedures includes the steps of securing a proximal end of a ligating instrument externally of the body with one hand, introducing a distal end of the ligating instrument at a surgical site in the body through a portal formed in tissue of the body, placing a length of ligature material carried by the ligating instrument around anatomical tissue to be ligated, moving an operating member of the ligating instrument with the same hand as that securing the proximal end to pull the ligature material through the ligating instrument to tighten the ligature material around the anatomical tissue to form a ligature and actuating a cutter of the ligating instrument to cut the ligature material away from the ligature.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention pertains to ligating instruments and, moreparticularly, to ligating instruments particularly useful in endoscopicoperative procedures to ligate anatomical tissue and methods of ligatinganatomical tissue in endoscopic operative procedures.

2. Discussion of the Prior Art

Closed, or endoscopic, surgery, also known as least-invasive surgery,has become extremely popular for use in conducting many variousprocedures such as, for example, laparoscopy (pelviscopy),gastroentroscopy, laryngobronchoscopy and arthroscopy. In endoscopicoperative procedures, access to surgical sites in the body is gainedthrough portals of minimal size formed in tissue of the body to allowinstruments to be introduced at the surgical sites via the portals.Endoscopic surgery provides many benefits over open surgery, whichtypically requires skin incisions of substantial size, including minimalinvasiveness and trauma, avoidance of complications due to surgery,greatly reduced wound healing times, patient discomfort andhospitalization and rehabilitation times and concomitant cost savingsassociated with shorter hospital stays and performing surgery withoutgeneral anesthesia and in non-hospital or out-patient surgery sites.Ligating anatomical tissue is a time consuming and tedious part of bothendoscopic and open operative procedures due to the difficulty involvedin applying an occluding ligature in anatomical tubular or non-tubulartissue or organ structure as is desirable in occluding or tying organand tissue structure in many various procedures. Ligating anatomicaltissue is particularly difficult in endoscopic surgery due to thelimited room for maneuverability at the surgical site and thecomplicated operative steps required; and, accordingly, the advantagesof endoscopic surgery are sometimes outweighed by the disadvantagescaused by the length of time required to perform endoscopic procedureswhere such time is significantly extended due to the time required forligation. Because endoscopic surgery is greatly preferred over opensurgery, much effort has been spent to develop techniques forfacilitating tissue ligation. One technique involves the use of ligatingdevices such as, for example, the Endoloop™ manufactured by Ethicon,Inc. Such ligating devices typically include an elongate tubular memberdefining a lumen for passage therethrough of a length of ligaturematerial, the ligature material having an end secured to a proximal endof the tubular member. A portion of the ligature material disposedexternally of a distal end of the tubular member is formed as a ligatureloop, the loop being made by passing the ligature material through aknot formed in an end of the ligature material externally of the tubularmember distal end. In use, the tubular member distal end is introduced,typically via a portal sleeve, at a surgical site in the body through aportal of minimal size formed in tissue of the body, with the proximalend of the tubular member held and secured externally of the body. Theligature loop is positioned around tissue to be ligated within the body;and, once the tissue is properly positioned within the loop, the tubularmember is broken or fractured to break off or separate the proximal endfrom the remainder thereof. The ligature material can then be pulled,via the broken off proximal end, through the lumen of the tubular memberwhile the knot, which is larger than the lumen at the tubular memberdistal end, remains held externally of the distal end such that the loopis reduced or tightened around the tissue to form a ligature. Once theligature is formed, a surgical instrument introduced at the surgicalsite from another portal is used to cut the ligature material away fromthe knot leaving the ligature in place. The ligating devices require useof both of the surgeon's hands, one hand to hold the tubular memberexternally of the body and the other to break off the proximal end andpull the ligature material therewith while the one hand continues tohold the tubular member. Forming ligatures in endoscopic operativeprocedures in accordance with the ligating devices is tedious and timeconsuming due to the number and complexity of the procedural stepsinvolved.

SUMMARY OF THE INVENTION

Accordingly, it is a primary object of the present invention to overcomethe aforementioned disadvantages of prior art ligating devices andmethods of ligating anatomical tissue in endoscopic operativeprocedures.

Another object of the present invention is to provide a ligatinginstrument for use in combination with presently available ligatingdevices to allow the ligating devices to be operated with one hand.

A further object of the present invention is to provide a ligatinginstrument having a length of ligature material extending therethroughfor forming a ligature in anatomical tissue and a cutter mounted thereonfor cutting the ligature material upon formation of a ligature with theligating instrument.

A still further object of the present invention is to provide a ligatinginstrument having a movable operating member for drawing ligaturematerial through the ligating instrument to tighten a ligature looparound anatomical tissue and relatively movable handle members operatedby squeezing action to obtain additional tightening of the ligature loopwith controlled tension.

Yet another object of the present invention is to provide a ligatinginstrument with a loop forming member at a distal end thereof to performthe function of a ligature knot and to permit ligature material to bedrawn through the ligating instrument in a single direction only.

An additional object of the present invention is to provide a ligatinginstrument for use with a ligating device having a proximal end securinga length of ligature material, the ligating instrument including amovable operating member for automatically breaking off the proximal endof the ligative device from the remainder thereof to draw the ligaturematerial through the ligating device in response to manual movement ofthe operating member.

It is also an object of the present invention to provide a ligatinginstrument having relatively movable handle members for drawing ligaturematerial through the ligating instrument to form a ligature inanatomical tissue and a frangible portion on the ligating instrument forpreventing relative movement of the handle members and for permittingrelative movement of the handle members when the frangible portion isbroken.

The present invention has as another object to provide a ligatinginstrument having a locking mechanism for preventing and selectivelypermitting movement of a movable cutter of the ligating instrument.

A further object of the present invention is to provide a ligatinginstrument having an operating member biased to draw ligature materialthrough the ligating instrument to tighten the ligature material aroundanatomical tissue and a release mechanism for releasing the operatingmember to automatically draw the ligature material through the ligatinginstrument due to the bias.

An additional object of the present invention is to provide a ligatinginstrument having a movable operating member for moving ligaturematerial through the ligating instrument to increase the size of aligature loop in the ligature material to allow the ligature loop to bepositioned around anatomical tissue and to reduce the size of the looparound the tissue in response to movement of the operating member.

A still further object of the present invention is to provide a ligatinginstrument for increasing the size of a ligature loop in a length ofligature material in response to manual movement of an operating memberand automatically reducing the size of the ligature loop in response tomovement of the operating member by a bias device.

Another object of the present invention is to provide a method ofligating anatomical tissue in endoscopic operative procedures includingsecuring a ligating instrument with one hand externally of the body,moving an operating member of the ligating instrument with the one handto draw ligature material through the ligating instrument to tighten theligature material around tissue to form a ligature and actuating acutter of the ligating instrument to cut the ligature material away fromthe ligature.

Some of the advantages of the present invention are that operation ofpresently available ligating devices is simplified and facilitated, thetime required to ligate anatomical tissue in endoscopic operativeprocedures is reduced, endoscopic operative procedures can be expandedto many areas due to the savings in time associated with the presentinvention, ligating anatomical tissue can be accomplished manually withthumb or squeezing action of one of the surgeon's hands or automaticallyby release of an operating member, where thumb action is utilized toform a ligature, the thumb action can be followed by the squeezingaction to obtain additional tightening of the ligature with controlledtension, a cutter can be integrated into the ligating instrument thuslyeliminating the need for extraneous cutting instruments introducedthrough separate portals, ligature material can be pulled through theligating instrument and a cutter for cutting the ligature material canbe actuated with a single hand and, through the use of lockingmechanisms on the ligating instrument, tightening of the ligature looparound anatomical tissue and cutting of the ligature material can beprevented until optimal positioning and tightening of the loop isassured, respectively, the size of a ligature loop can be increased andreduced with one hand operation of the ligating instrument, with theligating instrument, a ligature loop can be reduced in size tofacilitate introduction through portal sleeves and increased in sizethereafter to be positioned around anatomical tissue and the ligatinginstrument can be economically manufactured to be reusable or disposablefor single patient use.

These and other objects, benefits and advantages are obtained with thepresent invention as characterized in a ligating instrument for ligatinganatomical tissue alone or in combination with a ligating device. Wherethe ligating instrument is used in combination with a ligating device,the instrument includes a sleeve for receiving an end of the ligatingdevice, a handle for being grasped by the surgeon with one hand to holdthe ligating device and an operating member for securing a length ofligature material extending through the ligating device, the operatingmember being movable by the same hand as that grasping the handle topull the ligature material through the ligating device such that aligature loop disposed externally of the ligating device is reduced insize or tightened around anatomical tissue. Where the ligatinginstrument is used alone, the instrument includes an outer memberdefining a lumen for passage therethrough of a length of ligaturematerial, a handle for being grasped by a surgeon with one hand and anoperating member secured to an end of the ligature material for pullingthe ligature material through the outer member to tighten a ligatureloop of the ligature material around anatomical tissue to form aligature in response to movement of the operating member with the onehand. A cutter mounted within or externally of the ligating instrumentincludes an actuating member for being moved by the hand grasping theligating instrument to actuate a cutting member to cut the ligaturematerial away from the ligature leaving the ligature in place. Methodsof ligating anatomical tissue in endoscopic operative proceduresaccording to the present invention include the steps of securing aproximal end of a ligating instrument externally of the body with onehand, introducing a distal end of the ligating instrument at a surgicalsite within the body, positioning a length of ligature material carriedby the ligating instrument around anatomical tissue, moving an operatingmember of the ligating instrument with the same hand as that graspingthe ligating instrument to tighten the ligature material around thetissue to form a ligature and actuating a cutter of the ligatinginstrument to cut the ligature material away from the ligature.

These and other objects and advantages of the present invention willbecome apparent from the following description of the preferredembodiments taken in conjunction with the accompanying drawings whereinidentical reference numbers indicate identical parts or parts providingidentical functions.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a perspective view of a ligating device with which theligating instrument of the present invention can be used.

FIG. 2 is a perspective view of a ligating instrument according to thepresent invention.

FIG. 3 is a broken side view, partly in section, illustrating theligating instrument of FIG. 2 in use with the ligating device of FIG. 1.

FIG. 4 is a side view, partly in section, of a modification of theligating instrument according to the present invention.

FIG. 5 is a broken top view, partly in section, of the ligatinginstrument of FIG. 4.

FIG. 6 is a broken view, partly in section, of another modification ofthe ligating instrument according to the present invention.

FIG. 7 is a broken perspective view of the cutter member of the ligatinginstrument of FIG. 6.

FIG. 8 is a broken side view, partly in section, of an additionalmodification of the ligating instrument according to the presentinvention.

FIG. 9 is a broken side view, partly in section, of still anothermodification of the ligating instrument according to the presentinvention.

FIG. 10 is a broken side view, partly in section, of a furthermodification of the ligating instrument according to the presentinvention.

FIG. 11 is a broken side view, partly in section, of an additionalmodification of the ligating instrument according to the presentinvention.

FIG. 12 is a broken side view, partly in section, of still a furthermodification of the ligating instrument according to the presentinvention.

FIG. 13 is a broken side view, partly in section, of an additionalmodification of the ligating instrument according to the presentinvention.

FIG. 14 is a rear view of the operating member of the ligatinginstrument of FIG. 13.

FIG. 15 is a broken side view of the operating member of FIG. 14.

FIG. 16 is an opposing broken side view of the operating member of FIG.14.

FIG. 17 is a broken top view of the operating member of FIG. 14.

DESCRIPTION OF THE PREFERRED EMBODIMENTS

A ligating instrument 20 according to the present invention is shown inFIGS. 2 and 3, the ligating instrument 20 being in the nature of anaccessory or adapter for use in combination with a ligating device 22,such as the Endoloop™ made by Ethicon, Inc. Ligating device 22, as shownin FIGS. 1 and 3, typically includes an elongate tubular member 24having a tapered distal end 26, a proximal end 28 and a length ofligature or suture material 30 extending through the lumen of thetubular member. The ligature material 30 has an end secured to theproximal end 28 of the tubular member and is formed, externally of thedistal end 26, as a ligature loop 32 for receiving anatomical tissue tobe ligated. Loop 32 is made by the ligature material passing through aligature knot 34, such as a slip or hangman's knot, formed in an end ofthe ligature material externally of the tubular member distal end 26.The ligature knot 34 is larger in size than the lumen of the tubularmember at distal end 26 such that the ligature material can be pulledthrough the knot and the lumen of the ligating instrument while the knotremains held externally of the tubular member distal end to reduce thesize of the ligature loop and thusly close or tighten the loop aroundanatomical tissue to form a ligature. The proximal end 28 of the tubularmember is breakable or frangible such that the proximal end can beseparated or broken off from the remainder of the tubular member at abreak point 36 to permit the ligature material to be manually pulled,via the broken off proximal end, in a proximal direction through thelumen of the tubular member when forming a ligature with the loop 32.When used in endoscopic operative procedures, the ligating device 22 isintroduced, typically through a portal sleeve inserted in a portal ofminimal size formed in tissue of the body, at a surgical site in thebody, and the loop 32 is positioned around anatomical tissue to beligated. Operation of the ligating device 22 requires use of both of thesurgeon's hands in that one hand must be used to hold the tubular memberexternally of the body while the other hand must be used to break offthe proximal end and, via the broken off proximal end, manually pull theligature material 30 in a proximal direction through the ligating deviceto tighten the loop 32 around the anatomical tissue.

The ligating instrument 20 can be used in combination with the ligatingdevice 22 to convert the ligating device to one-handed operation andincludes a sleeve 38 for receiving the tubular member 24, a handle 40including a U-shaped handle member 41 extending outwardly from thesleeve for being grasped by a surgeon with one hand and an operatingmechanism including a movable operating member 42 coupled with thesleeve 38 for pulling or drawing the ligature material 30 through theligating device 22 in response to movement of the operating member bythe surgeon's finger. Operating member 42 is in the nature of a rolleror wheel including a pair of generally circular disks or plates 44mounted in spaced relation on a spool (not shown) rotatably mounted on apin or axle 46 secured to a mounting member 48 including a pair ofmounting bars 49 which, in turn, are secured to sleeve 38, such as byscrews, to couple the operating member 42 with the sleeve. Handle member41 is configured to facilitate grasping by a surgeon with one hand whilethe thumb of the same hand can be utilized to engage and move theoperating member. Sleeve 38 can have an inner surface sized tofrictionally engage and retain the tubular member 24 of ligating device22 and a set screw 55 can be provided in a threaded hole in the sleeveto engage and secure the tubular member therein as is useful where theouter diameter of the tubular member is smaller than the inner diameterof sleeve 38. A tube 57 can be mounted between the plates 44 inlongitudinal, axial alignment with sleeve 38, the tube rotating with theoperating member and having a lumen sized to frictionally engage andhold the proximal end 28 of a tubular member 24 inserted through sleeve38. In this manner, the proximal end 28 can be broken away from theremainder of the tubular member automatically in response to rotation ofthe operating member as will be explained further below. Where it is notdesired to break off the proximal end 28 automatically with rotation ofthe operating member or the tubular member is of a size too small to beheld in the tube 57, the proximal end can be broken off before or afterinsertion of the tubular member in sleeve 38 and the ligature material30 wrapped or wound around the spool of the operating member. A notch orslit 54 is formed in one of the plates 44 for securing a portion of theligature material to the operating member 42 when the ligating materialis wound therearound. It will be appreciated that various lockingdevices or latches, such as set screws, can be used on tube 57 forsecuring tubular members that are too small to be frictionally engagedby the inner diameter surface of the tube.

According to a method of operation for the ligating instrument 20 inendoscopic operative procedures, the tubular member is inserted throughthe sleeve 38 to be frictionally retained therein with the proximal end28 held in tube 57 as shown in FIG. 3. Where automatic separation of theproximal end is not desired, the proximal end 28 of the ligating device22 is broken away from the remainder of the tubular member 24 at breakpoint 36, and the broken off proximal end is grasped and utilized towind the ligature material 30 around the spool of the operating member42. A portion of the ligature material 30 is inserted in notch 54, thenotch serving to hold or secure the ligature material to the operatingmember with the proximal end 28 of the tubular member serving as anenlargement further preventing disengagement of the suture material fromthe operating member. Where automatic separation of the tubular memberproximal end is desired, the proximal end 28 is inserted in tube 57 tobe held therein. The handle member 41 is grasped by the surgeon with onehand, and the distal end of the ligating device 22 is introduced at asurgical site in the body through a portal of minimal size formed intissue of the body, the ligating device typically being introducedthrough a portal sleeve positioned in the portal. With the ligatingdevice 22 held externally of the body via handle 40, ligature loop 32 ispositioned around anatomical tissue to be ligated. Once the anatomicaltissue to be ligated is properly positioned within the ligature loop 32,the operating member 42 is rotated by the thumb of the same hand as thatgrasping the handle member. Rotation of the operating member causes theligature material 30 to be pulled or drawn in a proximal directionthrough the lumen of the tubular member 24 and, therefore, through theligature knot 34, the knot being held externally adjacent the distal end26 of the ligating device such that the loop 32 is reduced in size,tightened or closed around the anatomical tissue to form a ligature.Where the proximal end 28 was inserted in tube 57, rotation of theoperating member causes the proximal end 28 to be automaticallyseparated from the remainder of the tubular member as shown in FIG. 3.Rotation of the operating member 42 by the thumb of the surgeon's handcan be controlled to obtain a desired tension for the ligature. In thecase of the instrument 20, a cutting instrument is introduced at thesurgical site to cut the ligature material away from the knot leavingthe ligature in place; however, various types of cutters can be mountedon the instrument 20 to be operated by the same hand as that graspingthe instrument to cut the ligature material as will be explained below.

Ligating instrument 20 can be designed in many various ways to receiveor mount the ligating device 22 and provide a handle to be gripped by asingle hand of the surgeon for holding the ligating device externally ofthe body. Various components and mechanisms including mechanical latchesand locks, such as set screws 55 can be used to retain the ligatingdevice 22 on the ligating instrument 20 in addition to the frictionalretention shown. The handle 40 can have various configurations tofacilitate grasping by the surgeon with one hand and can include one ormore than one handle member. Various types of rotatable as well asnon-rotatable movable operating members can be utilized in the ligatinginstrument to be moved or operated by the same hand as that gripping thehandle to draw the ligature material in a proximal direction through theligating device. Where the operating member is in the form of a rolleror wheel, one or more plates 44 can be utilized to mount a spool forwinding the ligature material. The operating member can be mounted formovement in a single direction only to permit proximal movement of theligature material through the ligating device while preventing distalmovement of the ligature material therethrough to prevent loosening ofthe ligature. Various devices can be used to adapt the operating memberfor one-way operation, such as a ratchet and pawl arrangement. Theoperating member 42 can be coupled with the sleeve or the handle andvarious mounting members can be utilized to couple the operating memberwith the sleeve or handle. The ligature material can be secured to theoperating mechanism in many ways in addition to the tube and notchshown. The operating member can be longitudinally aligned with thesleeve as shown or the operating member can be longitudinally, angularlyor laterally offset from the sleeve. The operating member can bepositioned to allow insertion of the ligating device in the ligatinginstrument from either a proximal or distal direction. The operatingmember can be rotated to separate the tubular member proximal end priorto or after introduction of the instrument at the surgical site. Theligature loop does not have to be formed prior to introduction of theligating device at the surgical site but, rather, the ligature materialcan be made into a loop within the body. The ligature loop itself can bemade in many ways, such as by suturing the tissue to be ligated with aneedle attached to the ligature material externally of the ligatingdevice, making a knot in the ligature material with a portion of theligature material passing through the knot to form a loop around thetissue, cutting an end of the ligature material to remove the needle,and tightening the ligature material around the tissue in response tomovement of the material through the ligating device. The sleeve, handleand mounting member can be made as one piece of unitary, integralconstruction or as separate pieces. The operating member can be made asone piece of unitary, integral construction or as separate pieces, andnon-movable portions of the operating member can be formed integrally,unitarily with the sleeve, handle or mounting member. The ligatinginstrument 20 can be reusable for use with various ligating devices, orthe ligating instrument can be disposable for single patient use.

Where it is desired to provide automatic rather than manual operation ofthe operating mechanism, the operating member 42 can be replaced withthe operating member 342 illustrated in FIG. 14. Operating member 342includes a roller or wheel and a bias device such as a spring 247mounted, such as in torsion, to bias the roller to pull the ligaturematerial in a proximal direction through the ligating device. A releasemember 248 is pivotally mounted on the operating mechanism to position apawl 74 in engagement with a ratchet tooth 72 on the operating member toprevent rotation of the operating member and, therefore, proximalmovement of the ligature material, due to the rotational bias. In use,the ligature material is secured to the operating member 342 with theoperating member held by pawl 74 against movement from the rotationalbias, and the ligature loop is placed around tissue. Release member 248is pivoted to disengage pawl 74 from the ratchet tooth causing theoperating member to be automatically rotated to draw the ligaturematerial through the ligating device and tighten the ligature looparound the tissue.

A modification of a ligating instrument according to the presentinvention is illustrated at 60 in FIGS. 4 and 5. Ligating instrument 60is designed to be used in combination with a ligating device 22 andincludes a sleeve 38, a handle 40 coupled with sleeve 38 and anoperating member 42 for securing an end of ligature material 30 ofligating device 22. Handle 40 includes a handle member 62 and a flaredhand grip 64, the hand grip being disposed distally of the handle member62 at a distal end of a mounting member 48. Mounting member 48 caninclude a sleeve, as shown, connected with the operating member 42 orthe mounting member can have a semi-circular or any other desiredconfiguration in cross-section, the mounting member extendinglongitudinally between the hand grip and the operating member. Mountingmember 48 defines a longitudinal recess 65 for accommodating the tubularmember 24 of ligating device 22, and the hand grip has a longitudinalpassage 66 therein axially aligned with the recess of the mountingmember, the diameter of passage 66 being sized to allow passagetherethrough of the tubular member 24. Operating member 42 is rotatablymounted in recess 65 and is in the nature of a ratchet wheel including apair of generally circular disks or plates 44 rigidly connected inspaced relation by a spool 70 rotatably mounted on the mounting memberwith the spool aligned with and extending in a direction transverse to alongitudinal axis of the instrument. Ratchet teeth 72 are disposed alongthe circumferences of plates 44, and the wall of the mounting member isbent or curved outwardly to form catches or pawls 74 for engaging teeth72 to prevent rotational movement of the operating member in acounterclockwise direction looking at FIG. 4 while permitting rotationalmovement of the operating member in a clockwise direction. Handle member62 includes a generally rectangular frame 79 joined to sleeve 38, thesleeve being mounted for longitudinal movement in the recess 65 of themounting member with the frame extending through a longitudinal slot 80in the mounting member. A forward or distal wall of the handle memberhas a channel 86 therein disposed at an angle with the longitudinal axisof the ligating instrument, the channel 86 communicating with the lumenof sleeve 38. A latch 88 is disposed within the channel 86 to beoperated by a latch lever 90 pivotally mounted on the forward wall. Thelatch lever 90 is movable between an unlatched position wherein thelatch 88 does not project into the lumen of the sleeve 38 as shown inFIG. 4 and a latched position wherein the latch 88 is moved by the latchlever 90 to project or protrude into the sleeve lumen and secure orsqueeze the tubular member 24 of ligating device 22 therein.

According to a method of operation for the ligating instrument 60 inendoscopic operative procedures, the tubular member 24 of ligatingdevice 22 with proximal end 28 broken away therefrom is inserted, viathe passage 66 of hand grip 64 and recess 65 of mounting member 48 intothe lumen of sleeve 38. The latch lever 90 is pivoted or rotated in acounterclockwise direction looking at FIG. 4 causing the latch 88 to bemoved in the direction of the instrument longitudinal axis to engage orsqueeze the tubular member 24 and secure the tubular member within theligating instrument. The ligature material 30 is wrapped or wound aroundthe spool 70, and the wall of the mounting member proximally of thesleeve can be open, as shown in FIG. 5 to provide the room necessary towind the ligature material around the spool. A portion of the ligaturematerial is inserted in a clip 92 on the spool and is thusly secured tothe operating member 42. A tube 57 can be utilized with the instrument60 to provide automatic separation of the tubular member proximal end.The handle member 62 is grasped by the surgeon with one hand and thedistal end of the ligating device 22 is inserted at a surgical site inthe body as previously described. Once the ligature loop of the ligaturematerial 30 has been positioned around anatomical tissue to be ligated,the operating member 42 is rotated by the thumb of the same handgrasping the handle member 62 causing the ratchet wheel to rotate andpull the ligature material through the ligating device 22 to reduce thesize of the ligature loop around the tissue. Teeth 72 move past thepawls 74 during clockwise movement of the operating member, the pawls 74engaging successive teeth 72 to provide fixed, incremental positions forthe operating member to facilitate precision tightening of the ligatureloop while preventing movement of the ligature material through theligating device in a distal direction and, therefore, loosening of theligature. Once the desired final tension for the ligature has beenapproximated by pulling the ligature material via the operating member,the surgeon grips the flared hand grip 64 with the middle and index orother fingers of the same hand while continuing to hold the handlemember 62. The surgeon then squeezes the hand, moving the operatingmember proximally such that the ligature material secured to theoperating member is moved in a proximal direction causing the ligatureto be further tightened with controlled tension. Accordingly, theoperating member for the instrument 60 can be moved rotatably toapproximate the final ligature and longitudinally to tighten theligature loop with controlled tension with one hand. By providinginitial reduction of the ligature loop via movement of the operatingmember in a rotational direction followed by additional tightening viamovement of the operating member in a longitudinal direction, ligaturescan be precisely tensioned with a single hand utilized to perform allsteps of the ligating procedure. It should be appreciated that where theligature loop can be tightened to the desired final tension viasqueezing of the handle, the roller is not necessary.

Another modification of a ligating instrument according to the presentinvention is illustrated at 100 in FIG. 6. Instrument 100 is designedfor use in combination with a ligating device 22 and includes an outertubular member 102 connected with a handle 40, an operating member 42and a cutter 104 mounted in the lumen of tubular member 102. Tubularmember 102 has a tapered distal end 106 and a proximal end coupled withhandle 40. Handle 40 includes an angled handle member 110 extendingoutwardly from the tubular member 102 and angled toward the distal endto facilitate grasping by a surgeon with one hand. Operating member 42is in the nature of a roller or wheel for securing an end of theligature material 30 extending through the ligating device 22 aspreviously described and is coupled with handle 40 by mounting member 48including mounting bar 49 such that the operating member is offset fromand not aligned with a longitudinal axis of the ligating instrument. Theoperating member 42 includes plates 44 connected by spool 70 and ismounted on the mounting bar for rotation in clockwise andcounterclockwise directions. Ratchet teeth 72 are disposed along thecircumference of the spool at equally spaced locations therealong. Apawl or catch 74 is disposed on the mounting member to engage the teeth72 when the operating member is moved counterclockwise such thatcounterclockwise movement of the operating member is limited to the arc,spacing or distance between the teeth, the pawl 74 being configured toallow movement of the teeth therepast in a clockwise direction. Cutter104 includes as inner tubular member concentrically disposed within theouter tubular member 102 and having a proximal end extending proximallythrough the lumen of the outer tubular member to terminate at anactuating member 112 such as a flange, button or knob. A spring 114 isconnected between the actuating button 112 and the proximal end of theouter tubular member to position a cutting member 116 at a distal end ofthe cutter proximally of an angled inner surface 123 of the tapereddistal end 106 of the outer tubular member 102. As shown in FIG. 7,cutting member 116 includes a pair of opposing, longitudinally, distallyextending cutting fingers or prongs 120 terminating at angled distalcutting blades or surfaces 122 that are moved by the angled innersurface 123 in the direction of the longitudinal axis of the instrumentwhen the cutter is moved in a distal direction relative to the outertubular member. The cutter 104 can be a tubular member with fingers 120extending longitudinally, distally therefrom as shown or the cutter canbe formed as a plurality of interconnected, elongate fingers or prongsextending the length of the cutter.

According to a method of operation for the ligating instrument 100 inendoscopic operative procedures, a ligating device 22 is inserted in theinstrument 100 via the cutter proximal end to position the distal end 26of the ligating device proximally of the angled surface 123. If notalready broken away from the tubular member 24, the ligating deviceproximal end can be broken at the break point and the ligature material30 secured thereto by slit 54, a clip or any other suitable device, orthe proximal end can be inserted in a tube 57 for breaking off theproximal end automatically. Where the ligature material can be woundaround the operating member several times, a securing device may not benecessary. The handle 40 is grasped by the surgeon with one hand, andthe distal end 106 of the ligating instrument is introduced at asurgical site in the body as previously described. Once anatomicaltissue to be ligated has been positioned within the ligature loop 32,the operating member 42 is rotated by the thumb of the hand gripping thehandle to pull the ligature material through the ligating device andthusly tighten the ligature loop to form a ligature in the anatomicaltissue. The ligature is tightened as desired via the operating member,and manual rotation of the operating member in the clockwise directionis stopped just prior to a tooth 72 being moved past the pawl 74. Theoperating member is then moved by the thumb in a counterclockwisedirection until a preceding tooth is engaged by the pawl, the precedingtooth and pawl serving as a positive stop limiting counterclockwisemovement of the operating member. The slack created in the ligaturematerial with counterclockwise movement of the operating member allowsthe instrument to be moved proximally or backed away from knot 34. Thethumb of the hand grasping handle 40 is then utilized to engage theactuating button 112 and move the cutter 104 distally relative to theouter tubular member and the ligating device against the force of spring114 such that the fingers 120 are forced by the inner surface 123inwardly toward the instrument longitudinal axis causing the blades 122to cut or sever the suture material away from or proximally of knot 34leaving the ligature in place. Accordingly, the need for a separatecutting instrument inserted through a separate portal is eliminated.

Various types of cutters can be utilized in the instrument 100 to cut orsever the ligature material in response to movement of the cutter from aproximal end of the instrument. Various types of springs as well asother kinds of biasing devices can be utilized to position the cuttingmember to be engaged and moved by the outer tubular member to cut theligature material upon movement of the actuating member. The springs orbiasing devices can be arranged with the cutter and the outer tubularmember in many different ways. The operating member 42 can be arrangedin various angular or offset positions relative to the handle 40 andactuating member 112 to facilitate ease of operation of the operatingmember and actuating member by the hand gripping the handle. Variousdevices can be employed to limit counterclockwise movement of theoperating member and, where no limit on movement of the operating memberis desired, the positive stop can be eliminated. It will be appreciatedthat a bias device can be utilized in the instrument 100 to bias theoperating member in a counterclockwise direction to create a slack inthe ligature material upon release of the operating member followingclockwise rotation. The actuating member can have various configurationsand be mounted for movement in directions other than longitudinal, suchas inwardly toward the instrument axis as shown in FIG. 12.

An additional modification of a ligating instrument according to thepresent invention is illustrated in FIG. 8 at 150. Ligating instrument150 is designed for use alone in ligating tissue and includes an outertubular member 102, an operating member 42 connected by mounting member48 with the outer tubular member, a cutter 104 disposed within the outertubular member and a handle 40 connected with the outer tubular member.Outer tubular member 102 defines a lumen for receiving a length ofsuture or ligature material 30 and has a tapered distal end 106preventing passage through the instrument of a ligature knot (not shown)of a ligature loop formed in the ligature material externally of thedistal end. A proximal end of the outer tubular member is secured in atubular flange 156 of handle 40, the flange 156 being joined to a handlemember 41 extending outwardly from the outer tubular member with acurvature in a distal direction to facilitate grasping by a surgeon. Theouter tubular member 102 can be secured in flange 156 in many waysincluding frictionally, adhesively or by locking devices and the like.By forming the handle unitarily, integrally with the outer tubularmember, the flange 156 can be eliminated. Cutter 104 includes elongatefingers or prongs disposed within the outer tubular member 102 forpassage therethrough by the ligature material and terminates proximallyat an actuating member or end wall 112 disposed proximally of the outertubular member proximal end. An aperture is formed in the end wall toallow passage therethrough of the ligature material 30. A spring 114 isconnected between the flange 156 and the actuating member to position acutter member 116 on a distal end of the cutter proximally of nubs orprojections 118 formed on an internal surface of the outer tubularmember such that angled cutter blades or surfaces 122 on the fingers ofthe cutter will be engaged by the nubs upon movement of the cutterdistally via the actuating member. Operating member 42 is in the natureof a roller or wheel, and the roller can be rotatable clockwise andcounterclockwise, one-way rotatable, biased or a ratchet wheel aspreviously described.

According to a method of operation for ligating instrument 150 inendoscopic operative procedures, distal end 106 is introduced at asurgical site within the body while the instrument is grasped and held,externally of the body, via handle 40 by a surgeon's one hand. The thumbof the same hand as that grasping the handle is utilized to move theoperating member 42 to pull the ligature material 30 in a proximaldirection through the instrument. Once a ligature is formed inanatomical tissue, the thumb of the same hand is utilized to engage theactuating member 112 and move the cutter 104 distally such that angledcutter surfaces on the cutter fingers are engaged by nubs 118 causingthe cutting blades 122 to be moved inwardly toward a longitudinal axisof the instrument to sever and cut the ligature material away from theligature knot. The cutter surfaces and the rounded nubs 118 can havevarious configurations to cooperate to move the cutting blades intocontact with the ligature material, and the positions of the cuttersurfaces and the nubs can be reversed with the cutting member providedwith nubs and the outer tubular member provided with surfaces tocooperate with the nubs to move the blades into contact with theligature material. The ligature material can be formed into a loopbefore or after introduction of the instrument at the surgical site, andthe loop can be formed prior to the ligature material being placedaround the tissue or by being placed in the tissue such as by suturingwith a needle.

Another modification of a ligating instrument according to the presentinvention is shown in FIG. 9 at 160. Ligating instrument 160 is for usealone in ligating anatomical tissue and includes an outer tubular member102, a handle 40 coupled with the outer tubular member, an operatingmember 42 and a cutter 104 disposed within the outer tubular member.Outer tubular member 102 defines a lumen for passage of ligaturematerial 30 therethrough and has a tapered distal end 106 for preventingpassage through the instrument by a ligature knot. The outer tubularmember 102 terminates proximally at a handle member 162 of handle 40,the handle member 162 extending outwardly from the outer tubular memberto define a hand grip 161 for being grasped by the hand of a surgeon andincluding an end wall 166 joined to the hand grip and extendingoutwardly from the outer tubular member diametrically opposite the handgrip. The handle member 162 can be formed integrally, unitarily as onepiece with the outer tubular member or the end wall and the hand grip ofhandle member 162 can be formed unitarily, integrally or as separatecomponents secured to the proximal end of the outer tubular member byany suitable means. Cutter 104 is disposed within the lumen of the outertubular member and terminates proximally at an actuating member orflange 112 disposed proximally of the proximal end of the outer tubularmember, the cutter defining a lumen or passage for passage therethroughof the ligature material. Handle 40 includes a second handle member 168in the form of a plate having an opening therein for passagetherethrough of the outer tubular member 102, the plate defining a handgrip 169 spaced distally from the hand grip 161 to be grasped, with thehand grip 161, by one hand. A connecting web 172 extends proximally fromthe handle member 168 through a slot in the end wall 166 and is angledtoward a longitudinal axis of the instrument 160 to mount a hollowcylindrical member 176 such that the lumens of the cylindrical member,the outer tubular member and the cutter are axially aligned. The outertubular member is slidably disposed within the opening in the handlemember 168, and a locking mechanism including a frangible or breakablelocking bar 180 is connected between the handle members 162 and 168 toprevent movement of the handle members relative to one another. Afrangible or breakable locking strip 182 is connected between thecylindrical member 176 and the end wall 166 to similarly preventrelative movement of the handle members. By connecting the locking strip182 with the actuating member 112, actuation of the cutter can beprevented until the locking strip is broken.

Operation of the instrument 160 in endoscopic operative procedures toform a ligature in anatomical tissue is similar to that previouslydescribed in that the handle 40 is gripped, via the handle members 162and 168, by a surgeon with one hand and the operating member 42 is movedwith the thumb of the same hand to draw the ligature material 30 in aproximal direction through the instrument. Once the ligature is formedin the anatomical tissue to approximately the desired tension, thelocking bar 180 and the strip 182 are broken with the same hand thatholds the handle members. The handle members 162 and 168 can be squeezedmoving the operating member proximally and causing the ligature materialto be drawn further in a proximal direction through the instrument forcontrolling the final tightening or tensioning of the ligature. Once theligature is properly tensioned, the thumb of the same hand can be usedto engage the actuating member and move the cutter 104 in a distaldirection to cut the ligature material as previously described. Thelocking strip provides redundant protection, in addition to the lockingbar, against movement of the handle members. Where redundant protectionis not desired, the locking strip can be connected between the cutterand a non-movable portion of the instrument to serve as a lockingmechanism for the cutter only. The locking bar and the locking strip canbe mounted and secured on the instrument in many various ways to preventmovement of the handle members and cutter.

A still further embodiment of a ligating instrument according to thepresent invention is illustrated at 190 in FIG. 10 and includes an outertubular member 102 coupled with a handle 40, an operating member 42connected with an end of a length of ligature material 30 extendingthrough the instrument and a cutter 104 disposed within the outertubular member 102. Outer tubular member 102 defines a lumen for passagetherethrough of the ligature material 30 and has a tapered distal end106 preventing passage therethrough by a loop forming or ball member 192performing the function of the ligature knot previously described. Ballmember 192 is attached to an end of the ligature material externally ofdistal end 106 and has a passage for receiving a length of the ligaturematerial to form a ligature loop 32. A plurality of protrusions 194 suchas barbs or serrations extend along the passage of the ball member, theprotrusions 194 being angled toward a proximal end of the instrument toprevent movement of the ligature material therethrough in a distaldirection while permitting movement of the ligature materialtherethrough in a proximal direction to reduce the size of the ligatureloop. Handle 40 includes a handle member 162 secured to a proximal endof the outer tubular member and having an end wall 166 extendingoutwardly from the outer tubular member diametrically opposite a handgrip 161 of the handle member. A handle member 168 of the handle 40 isin the form of a plate having an opening slidably receiving the outertubular member for longitudinal movement therethrough. Handle member 168defines a hand grip 169 disposed distally of the hand grip 161, and theoperating member is in the form of a connecting web 172 extending in aproximal direction from the handle member 168 through a slot in the endwall 166. The operating member is angled toward a longitudinal axis ofthe instrument to terminate at a hollow cylindrical member 176 having alumen axially aligned with the lumens of the outer tubular member andcutter. The ligature material 30 passes through the outer tubular membervia the cutter and extends through the lumen of the cylindrical member176 to terminate at a bump or knob 196 larger in size than thecylindrical member lumen, and the bump can be a knot, a knob or anyother protrusion or enlargement disposed proximally adjacent thecylindrical member of the operating member. Cutter 104 is disposedwithin the outer tubular member and terminates proximally at anactuating member or flange 112 disposed proximally of the outer tubularmember proximal end. A helical coil spring 198 is disposed around thecutter and is biased between the actuating flange and the handle member162 to bias the cutter in a proximal direction such that cutter member116 at a distal end thereof is disposed proximally of nubs 118 formed onan inner surface of the outer tubular member. A locking mechanismincluding a locking bar 180 hingedly mounted on one of the handlemembers can be provided to prevent relative movement of the handlemembers and, therefore, the operating member in a locked position forthe locking bar, the locking bar being pivotable to an unlocked positionto release the handle members and operating member for movement.

Operation of the instrument 190 is similar to that previously describedin that the distal end of the instrument 190 is introduced at a surgicalsite in the body while being held, externally of the body, by handlemembers 162 and 168. Ligature loop 32 is placed around anatomical tissueto be ligated, and the handle members 162 and 168 are squeezed with onehand, causing the ligature material 30, via engagement of knob 196 withoperating member 42 to be moved in a proximal direction through theinstrument. Once the ligature is formed, the thumb of the same handutilized to grip the handle 40 can be used to engage actuating flange112 to move the cutter 104 in a distal direction to cut the ligaturematerial. In addition to facilitating formation of the ligature loop,loop forming member 194 ensures that the loop is not increased in sizeor untightened during formation of the ligature. The loop forming membercan have any structural configuration providing a passage for receivingthe ligature material and a securement site for the end of the ligaturematerial while preventing passage of the loop forming member into theligating instrument.

An additional modification of a ligating instrument according to thepresent invention is illustrated at 200 in FIG. 11. Ligating instrument200 includes an outer tubular member 102 defining a lumen for passagetherethrough of ligature material 30, handle 40 coupled with outertubular member 102, operating member 42 connected to ligature material30 and cutter 104 disposed within outer tubular member 102. Outertubular member 102 has a tapered distal end 106 preventing passagetherethrough of a ligature knot or loop forming member and an openproximal end through which a proximal end of cutter 104 extends. Handle40 includes handle members 162 and 168 extending outwardly from theouter tubular member, the handle member 168 being spaced distally fromthe handle member 162 to allow grasping of the handle members with onehand. Handle member 168 has an opening therein allowing passagetherethrough of the outer tubular member and the operating member 42 isin the nature of a plate, strip or web of material extending proximallyfrom the handle member 168. The operating member is bent or angled inthe direction of a longitudinal axis of the instrument to terminate atan end 202 aligned with the lumens of the outer member and cutter, theligature material 30 extending proximally through the cutter and beingsecured to the end. Cutter 104 has an open proximal end through whichthe ligature material 30 extends and a distal cutting member 116disposed distally of nubs 118. An actuating arm 204 is angled outwardlyfrom the cutter proximal end and bent in a distal direction to extendthrough an opening in the hand grip of handle member 162, the actuatingarm terminating at an actuating member or button 112 disposed betweenthe handle members 162 and 168.

According to a method of operation for ligating instrument 200 inendoscopic operative procedures, the handle 40 is grasped by the surgeonwith one hand, and the distal end of the instrument is introduced at asurgical site in the body with the proximal end held, externally of thebody, via the handle members 162 and 168. A ligature loop of theligature material 30 disposed externally of the distal end 106 ispositioned around anatomical tissue to be ligated, and handle members162 and 168 are squeezed such that the ligature material is moved by theoperating member in a proximal direction through the instrument totighten the ligature loop around the anatomical tissue. Continuedsqueezing of the handle members results in the actuating member 112being engaged by the handle member 168 and moved proximally therebycausing the cutter 104 to be moved in the proximal direction to bepositioned by nubs 118 to cut the ligature material. The actuatingmember can be arranged on the instrument 200 in many various ways to bepositioned in the path of movement of one of the handle members toactuate the cutter such that tightening of the ligature loop and cuttingof the ligature material can be accomplished with a single motion.

A further modification of a ligating instrument according to the presentinvention for use alone in ligating anatomical tissue is illustrated at220 in FIG. 12 and includes an outer tubular member 102 having a tapereddistal end 106 and a proximal end terminating at a handle 40 serving asthe operating member for drawing ligature material 30 through theinstrument and a cutter 104 disposed within the outer tubular member.The handle 40 includes a spring 221 joined to the outer tubular memberproximal end and extending proximally in a direction outwardly from alongitudinal axis of the instrument 220 with a bulging configuration.The operating member includes the spring 221 and a toothed ratchet bar222 secured to an end of the ligature material 30, the ratchet bar beingmounted in a bushing 224 disposed in the proximal end of the outertubular member to guide movement of the ligature material. The ratchetbar extends proximally through the handle 40 to terminate at a bead 226disposed externally, proximally adjacent the spring 221 such that theratchet bar and, therefore, the ligature material, is moved in aproximal direction by the spring when the spring is collapsed, flattenedor moved in the direction of the longitudinal axis. Cutter 104terminates proximally at an actuating member 112 in the form of a spring228 extending through a longitudinal slot 229 in the outer tubularmember and connected between the outer tubular member and the cutterproximal end. The actuating member or spring has a bulging configurationto extend in a direction outwardly from the longitudinal axis such thatthe cutter is moved in a distal direction relative to the outer tubularmember when the spring is collapsed, flattened, compressed or movedtoward the longitudinal axis.

According to a method of operation for the ligating instrument 220 inendoscopic operative procedures, handle 40 is grasped by the surgeonwith one hand, and the distal end of the instrument is introduced at asurgical site in the body to position a ligature loop disposedexternally of the outer tubular member distal end around anatomicaltissue to be ligated. The operating member, spring 221 in the instrument220, is squeezed causing the spring to collapse or flatten thusly movingthe ratchet bar 222 and with it the ligature material 30 in a proximaldirection. Upon release of the handle 40, the spring 221 will return tothe bulging configuration with an end face 227 of the spring engagingthe teeth of the ratchet bar to hold the ligature material in position.The teeth of the ratchet bar can be angled toward the distal end of theinstrument to prevent movement of the ratchet bar and, therefore, theligature material, in a distal direction to prevent untightening of theligature loop while permitting proximal movement of the ligaturematerial. Once the ligature is formed in anatomical tissue, theactuating member, spring 228, is squeezed to collapse or flatten thespring causing the cutter to move distally to cut the ligature material.

An additional modification of a ligating instrument according to thepresent invention for use alone in ligating anatomical tissue isillustrated at 240 in FIG. 13 and includes an outer tubular member 102having an open distal end 106 and an open proximal end, a middle member241 disposed within the outer tubular member, a cutter 104 disposedwithin the middle member, a handle 40 mounting the middle member and aproximal end of the outer tubular member and a length of ligaturematerial 30 extending through the instrument 240. Middle member 241includes opposing grasping arms or prongs 242 extending longitudinally,distally to terminate at bumps 243 at a distal end of the middle member.Arms 242 are biased outwardly to an open position and are moved to aclosed position via engagement of bumps 243 with an inner surface of thewall of the outer member 102 when the middle member is disposed withinthe outer member as illustrated in FIG. 13. Nubs 118 are disposed alongan inner surface of arms 242 in opposing relation to move cuttingfingers 120 of cutter 104 inwardly in the direction of a longitudinalaxis of the instrument to cut ligature material 30 extending through thecutter. Middle member 241 extends through the open proximal end of theouter tubular member 102 to be disposed externally of the outer member,and handle 40 includes a U-shaped spring handle member 244 connected tothe middle member 241 externally of the outer member and to the outermember proximal end. Opposing legs 245 of handle member 244 are biasedto be spaced from each other as illustrated in FIG. 13 to position thebumps 243 on the middle member distal end within the outer tubularmember. Cutter 104 terminates proximally at an actuating member 112including a U-shaped spring 114 extending through a longitudinal slot246 in the middle member 241 and connected between the cutter proximalend and the leg 245 of handle member 244 attached to the middle member.Middle member 241 terminates proximally at an operating member 342securing an end of the ligature material extending through theinstrument 240. Ligature material 30 is formed into a ligature loop 332via a ligature knot 34, with the knot 34 being held in place within theouter member by the grasping arms 242 of the middle member asillustrated in FIG. 13. Ligature loop 332 is greatly reduced in size tobe disposed entirely within the outer tubular member to facilitateintroduction of the instrument at a surgical site in endoscopicoperative procedures. Operating member 342 is best illustrated in FIGS.14-17 and includes a roller or wheel having a pair of circular plates 44rigidly mounted in spaced relation by a spool 70 around which theligature material can be wound for securement to the operating member.Spool 70 is rotatably mounted on a pin or axle 46 secured between a pairof mounting bars 49 connected to the middle member. A bias deviceincluding a coil spring 247 is disposed around pin 46 and connectedbetween one of the plates 44 and the corresponding mounting bar 49 asillustrated in FIGS. 14 and 15, the spring being mounted in torsion torotationally bias the roller in a counterclockwise direction looking atFIG. 13. A plurality of ratchet teeth 72 are disposed along a side ofthe other of the plates 44 inwardly of the circumference thereof, theratchet teeth being angled outwardly from the side of the plate to beengaged by a pawl 74 carried on a release lever 248 pivotally mounted onthe pin 46 to prevent movement of the roller due to the rotational bias.Release lever 248 has a button for being selectively manually moved topivot the release lever to disengage the pawl 74 from a tooth 72permitting rotation of the roller automatically in the counterclockwisedirection by the bias device. In use, ligating instrument 240 isintroduced at a surgical site in the body with the ligature loop 332held by grasping arms 242 within the outer tubular member. The ligaturematerial 30 is wound several times around the spool 70 in a directionallowing the ligature material to be moved distally through theinstrument 240 in response to manual clockwise rotation of the rollerand proximally in response to counterclockwise rotation of the rollerdue to the torsional bias. Once a distal end of the instrument 240 hasbeen introduced at a surgical site in the body with handle 40 heldexternally of the body, the thumb of the hand grasping the handle isutilized to rotate the operating member 42 in a clockwise directionlooking at FIG. 13. Clockwise rotation of the operating member causesthe ligature material to be moved through the ligating instrument in adistal direction while the knot 34 remains held by the middle member toincrease the size of the ligature loop. The operating member is rotateduntil the ligature loop has been increased in size sufficiently to beplaced around anatomical tissue to be ligated. When the desired size forthe ligature loop has been obtained, the thumb can be removed from theoperating member with pawl 74 engaging a tooth 72 to preventcounterclockwise rotation of the operating member by the bias device.The anatomical tissue is positioned within the ligature loop 332 and thebutton 249 of the release lever 248 is moved as shown by the arrow inFIG. 17 causing pawl 74 to be disengaged from tooth 72 such that theoperating member is automatically rotated in a counterclockwisedirection looking at FIG. 13 due to the bias of spring 247. Withcounterclockwise direction of the operating member, the ligature loop332 will automatically be reduced in size or tightened around thetissue. Another manner in which the instrument 240 can be used involvesdisengaging pawl 74 from a tooth 72 prior to enlarging the ligature loopand thereafter rotating the operating member clockwise to increase thesize of the loop. While holding the operating member in position withthe thumb, the enlarged loop can be placed around anatomical tissue;and, thereafter, the thumb can be released from the operating membercausing the operating member to be rotated automatically in acounterclockwise direction to tighten the ligature loop around thetissue. Once a ligature has been formed in the tissue, actuating member112 is squeezed causing the cutter 104 to be moved distally within themiddle member such that cutting fingers 120 are moved by nubs 118inwardly to cut the ligature material away from knot 34. Once theligature material has been cut, handle 40 is squeezed drawing handlelegs 245 together to move the outer and middle members relative to oneanother such that the distal end of the middle member is disposed beyondthe distal end of the outer member. With the middle member distal endextended from the outer tubular member, the grasping arms 242 will bemoved outwardly due to the outward bias causing the knot 34 to bereleased from the grasping arms allowing the instrument 240 to beremoved from the body leaving the ligature in place. Squeezing of thehandle 40 can be stopped prior to removing the instrument from the bodyallowing legs 245 to again position the middle member distal end withinthe outer member to facilitate withdrawal through a portal sleeve.

Inasmuch as the present invention is subject to many variations,modifications and changes in detail, it is intended that all subjectmatter discussed above or shown in the accompanying drawings beinterpreted as illustrative only and not be taken in a limiting sense.

What is claimed is:
 1. A ligating instrument for ligating anatomicaltissue comprisinga ligating device including an elongate body having adistal end and a proximal end and a length of ligature materialextending through said body and secured to said proximal end, saidligature material being formed into a ligature loop disposed externallyof said distal end for being positioned around anatomical tissue to beligated, said proximal end being separable from the remainder of saidbody to allow said ligature material to be moved through said ligatingdevice to close said ligature loop around the anatomical tissue; and anadapter including means for receiving said ligating device, a handleconnected with said receiving means for being grasped by a hand of asurgeon and operating means coupled with said receiving means forsecuring said proximal end of said body, said operating means beingmovable manually by the hand grasping said handle to move said ligaturematerial through said ligating device to close said ligature loop andform a ligature in the anatomical tissue.
 2. The ligating instrument asrecited in claim 1 wherein said operating means includes a rotatableoperating member for being manually rotated by a finger of the handgrasping said handle.
 3. The ligating instrument as recited in claim 2wherein said rotatable operating member includes a roller.
 4. Theligating instrument as recited in claim 3 wherein said roller ismanually rotatable in a single direction.
 5. The ligating instrument asrecited in claim 4 further including means on said roller for preventingrotation of said roller in a direction other than said single direction.6. The ligating instrument as recited in claim 3 wherein said roller ismanually rotatable in clockwise and counterclockwise directions.
 7. Theligating instrument as recited in claim 6 wherein said adaptor furtherincludes means for limiting rotational movement of said roller in one ofsaid directions.
 8. The ligating instrument as recited in claim 1wherein said receiving means includes a sleeve.
 9. The ligatinginstrument as recited in claim 8 wherein said sleeve includes means forengaging said ligating device body and said engaging means includes asurface of said sleeve frictionally engaging said ligating device body.10. The ligating instrument as recited in claim 8 wherein said sleeveincludes means for engaging said ligating device body and said engagingmeans includes a latch.
 11. The ligating instrument as recited in claim1 wherein said handle includes means for further moving said ligaturematerial through said ligating device by the hand grasping said handleto tighten the ligature in anatomical tissue upon formation of theligature with said operating means.
 12. The ligating instrument asrecited in claim 1 further including a cutter carried by said receivingmeans for cutting said ligature material adjacent the ligature andactuating means coupled with said handle for actuating said cutter tocut said ligature material in response to movement of said actuatingmeans by the hand grasping said handle.
 13. The ligating instrument asrecited in claim 12 wherein said cutter is disposed within saidreceiving means.
 14. The ligating instrument as recited in claim 12wherein said cutter is disposed around said ligating device.
 15. Theligating instrument as recited in claim 12 wherein said ligating devicefurther includes a longitudinal axis and said actuating means includesan actuating member movable longitudinally along said axis.
 16. Theligating instrument as recited in claim 12 wherein said ligating devicefurther includes a longitudinal axis and said actuating means includesan actuating member movable in a direction transverse to said axis. 17.The ligating instrument as recited in claim 1 wherein said adaptorfurther includes means for separating said ligating device proximal endfrom said remainder of said ligating device body automatically inresponse to movement of said operating means.